EMPHASIS-HF MRA in Mild HFrEF — EECC MCQ
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Correct answer: A — EMPHASIS-HF demonstrated that eplerenone (up to 50 mg daily) reduced the composite of cardiovascular death or HF hospitalisation by 37% in mild HFrEF (NYHA II, LVEF ≤30% or ≤35% with QRS >130 ms) — extending the MRA benefit from NYHA III-IV (RALES) to NYHA II
EMPHASIS-HF (2011) extended the MRA evidence from severe HF (RALES — NYHA III-IV) to MILD HFrEF: 2,737 patients with NYHA II and LVEF ≤30% (or ≤35% with QRS >130 ms) were randomised to eplerenone (titrated to 50 mg daily) vs placebo on top of ACEi/ARB + beta-blocker. Results: 37% reduction in CV death or HF hospitalisation (primary composite), 24% all-cause mortality reduction. The trial was stopped early for overwhelming benefit. Combined with RALES (NYHA III-IV) and EPHESUS (post-MI HFrEF), this established MRA benefit across the full HFrEF severity spectrum. The ESC 2023 HF Guidelines give MRA a Class I recommendation for ALL symptomatic HFrEF (NYHA II-IV). Eplerenone is preferred over spironolactone when anti-androgenic effects (gynaecomastia) are problematic.
Reference: ESC (2023): HF Guidelines; EMPHASIS-HF Trial